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CDR Timothy Murray CHF Clinic Manager Internal Medicine Team Inpatient Pharmacy Clinical Coordinator Claremore Indian Hospital Clinical Assistant Professor.

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Presentation on theme: "CDR Timothy Murray CHF Clinic Manager Internal Medicine Team Inpatient Pharmacy Clinical Coordinator Claremore Indian Hospital Clinical Assistant Professor."— Presentation transcript:

1 CDR Timothy Murray CHF Clinic Manager Internal Medicine Team Inpatient Pharmacy Clinical Coordinator Claremore Indian Hospital Clinical Assistant Professor University of Oklahoma Primary Care Cardiology Update April 9, 2011

2  PT is a 37 yo white male whom is being consulted to the Internal Medicine service today secondary to an CHF exacerbation. JS presented to the ER with a 5 day history of increased shortness of breath and 10 lb weight increase.  Symptoms started after a recent trip where a “poor” diet was consumed.  Family Hx: DM, CAD  Social Hx: negative  PMH: HTN, CAD  Medication prior to admission:  Atenolol 25mg BID, aspirin 81mg daily, fish oil 1000mg daily, tamsulosin 0.4mg daily, KCL 8meq daily, furosemide 20mg daily

3 Vitals: BP- 152/77, HR-101, WT- 177lbs

4  Physical Exam:  CHEST/LUNGS:  Chest: Nontender  Lungs: RALES Bilateral mostly at right base, no wheezing  CARDOVASCULAR:  Cardiac: regular rate, regular rhythm, No murmur  Pulses: Equal, DIMINISHED Very diminished at feet.  Carotid: No bruit  JVD: + distended  Abd aorta: No Bruit  Lower ext: BILATERAL Edema of both legs mostly right side 3/4 and 2/4 at left.

5  PT is treated in the hospital for 3 days. Weight has decreased 15 lbs and he feels much better. PT is to be seen in the CHF clinic in 2weeks for medication adjustment, dietary education, and monitoring. Completed echocardiogram reveals an ejection fraction of 25%  PT returns to CHF clinic in 2wks with the following labs: PNBP: 3200

6  Based upon the above case what type of interventions would you have expected to have been performed? (during admission or in clinic) A. Continue all medications prior to admission B. Increase Atenolol, start an ace-inhibitor, & start an aldosterone antagonist C. DC atenolol, start metoprolol succinate, & start an ace-inhibitor D. DC atenolol, start carvedilol, & start an ace-inhibitor E. Just give up and discharge patient from clinic!!!

7  Heart failure (HF) is a major public health problem resulting in substantial morbidity and mortality  Major cost-driver of HF is high incidence of hospitalizations 1,2  JCAHO has initiated HF quality care indicators for hospitalized HF patients 1 American Heart Association Heart and Stroke Statistical Update. Dallas, Tex: American Heart Association; Population Group PrevalenceIncidenceMortality Hospital Discharges Cost Total population 4,900,000550,00051,546999,000 $24.3 billion 1

8 8% 10% 7% 14% 53% Hospitalization $13.6 Lost Productivity/ Mortality* $2.1 Home Healthcare $2.1 Drugs/Other Medical Durables $2.7 Physicians/Other Professionals $1.8 Nursing Home $3.5 *Lost future earnings of persons who will die in 2004, discounted by 3% AHA. Heart Disease and Stroke Statistics—2004 Update Total Cost $25.8 billion

9 17% Other 19% Failure to Seek Care 16% Inappropriate Rx Rx Noncompliance 24% Diet Noncompliance 24% Annals of Internal Medicine 122:415-21, 1995 Over 2/3 of HF Hospitalizations Preventable

10  Patients  Patient capture point  Have patient’s/family’s attention: “teachable moment”  Predictor of care in community  Hospital structure  Standardized processes / protocols / teams  Accrediting bodies for standards of care  Centers for Medicare and Medicaid Services—peer review organization

11 Improved use of evidence- based therapy Improved use of evidence- based therapy Improved symptom status and functional capacity Improved symptom status and functional capacity Improved QOL Improved QOL Reduction in hospitalization Reduction in hospitalization Decrease in total medical costs Decrease in total medical costs BenefitsDrawbacks Usual Care HF Disease Management Program HF Disease Management Program Moser DK, Mann DL. Circulation. 2002;105:2810–2812.

12  Where did our process break down and why no reduction in hospitalizations or re- hospitalizations?  Sub-optimal utilization of guidelines  No standardization of care (standing orders)  No team approach to treating CHF  No increase in intensity of HF care after hospital discharge

13  National registry  Develop a treatment plan (protocol)  Utilize a team approach to treating CHF  Provide a comprehensive service to monitor & make clinical alterations with patient’s treatment plan  Provide patient education & training to involve patients in their treatment plan  Follow-up on patients discharged after a CHF admission to avoid re-admission: CHF Clinic!!!!!!  Implement & utilize national standards of care for CHF  GET UP TO DATE WITH THE CHF GUIDELINES!  Document – Document - Document!

14  Center of Medicaid & Medicare Services  Compliance rates for discharging CHF pts  Joint Commission/ACC/AHA  CHF Performance Measures

15  CHF Core Measures  1. Documentation of discharge instructions  2. Left ventricular function assessment  3. Use of ACE-I or ARB in pts with left ventricular systolic failure  4. Documentation of smoking cessation

16  Hospitals should strongly consider implementing a process of care to ensure these measures are obtained and proper documentation occurs.  The principal outcome measure of the ADHERE Registry was to assess overall hospital adherence to each of these measures for participating hospitals.

17  CMS 2009 Documentation privileges for pharmacists!  Electronic Health Record advantages  GIPRA Measures/Performance Improvements  2010 CMS 30 day readmission policy changes  Beta Blockers?

18  Ace-Inhibitors  Beta-Blockers  Aldosterone Antagonists  ARBs  ISDN/Hydralazine  Diuretics  Digitalis  Antiplatelets  Statins  Fish Oils  Calcium Channel Blockers

19  CHF care driven by two sets of national guidelines  American College of Cardiology/American Heart Association  Heart Failure Society of America

20  Both organizations provide a set of detailed treatment guidelines for practitioners in an effort to optimize the management of chronic CHF.  Treatment guidelines provide an approach to practice evidence based medicine.

21  Heart Failure Society of America   Last update: June 2010  American College of Cardiology/American Heart Association   Last update: April 2009

22  2009 ACC/AHA recommendation for: “implementation of practice based guidelines utilizing multidisciplinary disease-management programs in efforts to assist in the treatment of patients with CHF”.

23  2010 HFSA recommendation for: “patients recently hospitalized for HF & other patients at high risk for HF decompensation should be considered for comprehensive HF disease management.”

24 Risk FactorGoal HypertensionGenerally < 130/80 DiabetesSee ADA guidelines 1 HyperlipidemiaSee NCEP guidelines 2 Inactivity20-30 min. aerobic 3-5 x wk. ObesityWeight reduction < 30 BMI AlcoholMen ≤ 2 drinks/day, women ≤ 1 SmokingCessation Dietary SodiumMaximum 2-3 g/day Journal of Cardiac Failure Vol. 16 No

25  ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with:  Coronary artery disease  Peripheral vascular disease  Stroke  Diabetes and another major risk factor Strength of Evidence = A  ACE inhibitors and beta blockers are recommended for all patients with prior MI. Strength of Evidence = A Journal of Cardiac Failure Vol. 16 No

26  Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest. NEJM 2000;342: (HOPE) Lancet 2003;362:782-8 (EUROPA ) Placebo Ramipril Placebo Perindopril 20% rel. risk red. p = % rel. risk red. p <.001 HOPE EUROPA

27  SAVE Study  All-cause mortality ↓19%  CV mortality ↓21%  HF development ↓37%  Recurrent MI ↓25% Placebo Captopril Years Mortality Rate 19% rel. risk reduction p = Pfeffer et al. NEJM 1992;327:669-77

28  ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%. Strength of Evidence = A  ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C  ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.  Post MI Strength of Evidence = B  Non Post-MI Strength of Evidence = C Journal of Cardiac Failure Vol. 16 No

29 SOLVD Prevention (Asymptomatic LVD)  20% death or HF hosp.  29% death or new HF CONSENSUS (Severe Heart Failure)  40% mortality at 6 mos.  31% mortality at 1 year  27% mortality at end of study SOLVD Investigators. N Engl J Med 1992;327: SOLVD Investigators. N Engl J Med 1991;325: CONSENSUS Study Trial Group. N Engl J Med 1987;316: (Chronic Heart Failure) SOLVD Treatment 16% mortality

30 Generic Name Trade NameInitial Daily Dose Target DoseMean Dose in Clinical Trials CaptoprilCapoten6.25 mg tid50 mg tid122.7 mg/day EnalaprilVasotec2.5 mg bid10 mg bid16.6 mg/day FosinoprilMonopril5-10 mg qd80 mg qdN/A LisinoprilZestril, Prinivil mg qd20 mg qd4.5 mg/day, 33.2 mg/day* QuinaprilAccupril5 mg bid80 mg qdN/A RamiprilAltace mg qd10 mg qdN/A TrandolaprilMavik1 mg qd4 mg qdN/A *No mortality difference between high and low dose groups, but 12% lower risk of death or hospitalization in high dose group vs. low dose group.

31  It is recommended that other therapy be substituted for ACE inhibitors in the following circumstances:  In patients who cannot tolerate ACE inhibitors due to cough, ARBs are recommended. Strength of Evidence = A  The combination of hydralazine and an oral nitrate may be considered in such patients not tolerating ARBs. Strength of Evidence = C  Patients intolerant to ACE inhibitors from hyperkalemia or renal insufficiency are likely to experience the same side effects with ARBs. In these cases, the combination of hydralazine and an oral nitrate should be considered. Strength of Evidence = C Journal of Cardiac Failure Vol. 16 No

32  Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%. Strength of Evidence = A  Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.  Post MI Strength of Evidence = B  Non Post-MI Strength of Evidence = C Journal of Cardiac Failure Vol. 16 No

33 Study Drug HF Severity Target Dose (mg) Outcome US Carvedilol 1 carvedilolmild/ moderate BID ↓48% disease progression (p=.007) CIBIS-II 2 bisoprololmoderate/ severe 10 QD↓34% mortality (p <.0001) MERIT-HF 3 metoprolol succinate mild/ moderate 200 QD↓34% mortality (p =.0062) COPERNICUS 4 carvedilolsevere25 BID↓35% mortality (p =.0014) CAPRICORN 5 carvedilolpost-MI LVD 25 BID↓23% mortality (p =.031) 1 Colucci WS et al. Circulation 1196;94: CIBIS II Investigators. Lancet 1999;353: MERIT-HF Study Group. Lancet 1999;353: Packer M et al. N Engl J Med 2001; The CAPRICORN Investigators. Lancet 2001;357:

34  Beta blocker therapy is recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents.  Whenever possible, beta blocker therapy should be initiated in the hospital at a low dose prior to discharge of stable patients. Strength of Evidence = B Journal of Cardiac Failure Vol. 16 No

35  Continuation of beta blocker therapy is recommended in most patients experiencing a symptomatic exacerbation of HF during chronic maintenance treatment, unless they develop cardiogenic shock, refractory volume overload, or symptomatic bradycardia. Strength of Evidence = C  Temporary dose reduction may be considered  Avoid abrupt discontinuation  Reinstate or gradually increase prior to discharge  Titrate dose to previously tolerated dose as soon as possible Journal of Cardiac Failure Vol. 16 No

36 Carvedilol Predischarge Initiation (n=185) Physician Discretion Postdischarge Initiation* (n=178) 18%Improvement Gattis WA et al. JACC 2004;43:

37 CONCOMITANT DISEASE  Beta blocker therapy is recommended in the great majority of patients with HF and reduced LVEF—even if there is concomitant diabetes, chronic obstructive lung disease or peripheral vascular disease.  Use with caution in patients with:  Diabetes with recurrent hypoglycemia  Asthma or resting limb ischemia.  Use with considerable caution in patients with marked bradycardia (<55 bpm) or marked hypotension (SBP < 80 mmHg).  Not recommended in patients with asthma with active bronchospasm. Strength of Evidence = C Journal of Cardiac Failure Vol. 16 No

38 COPERNICUS (carvedilol) 1 With diabetes Without diabetes MERIT-HF (ER metoprolol succinate) 2 With diabetes Without diabetes Mohacsi. Circulation. 2001;104(17):abstr Hjalmarson. JAMA. 2000;283(10):1295.

39 PRESERVED LVEF  Beta blocker treatment is recommended in patients with HF and preserved LVEF who have:  Prior MI Strength of Evidence = A  Hypertension Strength of Evidence = B  Atrial fib. requiring control of ventricular rate Strength of Evidence = B THE ELDERLY  Beta-blocker and ACE inhibitor therapy is recommended as standard therapy in all elderly patients with HF due to LV systolic dysfunction. Strength of Evidence = B  In the absence of contraindications, these therapies are also recommended in the very elderly (age > 80 years). Strength of Evidence = C Journal of Cardiac Failure Vol. 16 No

40 General considerations Initiate at low doses Up-titrate gradually, generally no sooner than at 2 week intervals Use target doses shown to be effective in clinical trials Aim to achieve target dose in 8-12 weeks Maintain at maximum tolerated dose If symptoms worsen or other side effects appear Adjust dose of diuretic or concomitant vasoactive med. Continue titration to target after symptoms return to baseline If up-titration continues to be difficult Prolong titration interval Reduce target dose Consider referral to a HF specialist Journal of Cardiac Failure Vol. 16 No

41 Generic Name Trade NameInitial Daily Dose Target DoseMean Dose in Clinical Trials BisoprololZebeta1.25 mg qd10 mg qd8.6 mg/day CarvedilolCoreg3.125 mg bid25 mg bid37 mg/day CarvedilolCoreg CR10 mg qd80 mg qd Metoprolol succinate CR/XL Toprol XL mg qd200 mg qd159 mg/day

42  ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency.  Strength of Evidence = A Journal of Cardiac Failure Vol. 16 No

43  Val-HeFT Valsartan Placebo p = Months Survival % CV Death or HF Hosp % Placebo Candesartan CHARM-Alternative HR 0.77, p = Months Maggioni AP et al. JACC 2002;40: Granger CB et al. Lancet 2003;362:772-6

44 Generic Name Trade NameInitial Daily Dose Target DoseMean Dose in Clinical Trials CandesartanAtacand4-8 mg qd32 mg qd24 mg/day LosartanCozaar mg qd150 mg qd129 mg/day ValsartanDiovan40 mg bid160 mg bid254 mg/day

45  An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have:  NYHA class IV HF (or class III, previously class IV) HF from reduced LVEF (≤ 35%)  One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker. Strength of Evidence = A Journal of Cardiac Failure Vol. 16 No

46  RALES (Advanced HF) EPHESUS (Post-MI) Spironolactone Placebo Months RR = 0.70 P < Eplerenone Placebo RR = 0.85 P < Pitt B. N Engl J Med 1999;341: Pitt B. N Engl J Med 2003;348: Probability of Survival

47  Aldosterone antagonists are not recommended when:  Creatinine > 2.5mg/dL (or clearance < 30 mL/min)  Serum potassium> 5.0 mmol/L  Therapy includes other potassium-sparing diuretics Strength of Evidence = A  It is recommended that potassium be measured at baseline, then 1 week, 1 month, and every 3 months Strength of Evidence = A  Supplemental potassium is not recommended unless potassium is < 4.0 mmol/L Strength of Evidence = A Journal of Cardiac Failure Vol. 16 No

48  Trial of 2737 patients with NYHA class 2 heart failure and an ejection fraction of no more than 35%.  Patients were randomized to eplerenone (up to 50mg daily) or placebo in addition to recommended therapy.  Measured outcomes included: cardiovascular death/heart-failure hospitalization, cardiovascular death, heart-failure hospitalization, and hospitalization for hyperkalemia.  Trial was stopped early at 21months.

49  EMPHASIS-HF Major results  Results in a 37% reduction in the primary end point of the composite of death from cardiovascular causes or hospitalization for heart failure!!  Hyperkalemia occurring in 11.8% of eplerenone patients vs 7.2% of those in placebo group!!! OutcomeEplerenone (%)Placebo (%)Adjusted hazard ratio (95% CI) P Cardiovascular death/heart- failure hospitalization ( )< Cardiovascular death ( )0.01 Heart-failure hospitalization ( )< Hospitalization for hyperkalemia ( )0.85

50  A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF:  NYHA III or IV HF Strength of Evidence = A  NYHA II HF Strength of Evidence = B Journal of Cardiac Failure Vol. 16 No

51 End point ISDN-HDZN (n=518) Placebo (n=532) p Primary end point composite score All-cause mortality (%) st HF hospitalization (%) Change in quality-of-life score at 6 months** Taylor AL et al. N Engl J Med 2004; 351;

52 Survival % Days Since Baseline Visit 43% Decrease in Mortality Fixed Dose ISDN/HDZN Placebo P = 0.01 Taylor AL et al. N Engl J Med 2004;351:

53  Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by:  Congestive symptoms  Signs of elevated filling pressures Strength of Evidence = A  Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF. Strength of Evidence = B Journal of Cardiac Failure Vol. 16 No

54  Restoration of normal volume status may require multiple adjustments.  Once a diuretic effect is achieved with short-acting loop diuretics, increase frequency to 2-3 times a day if necessary, rather than increasing a single dose. Strength of Evidence = B  Oral torsemide may be considered in patients exhibiting poor absorption of oral medication or erratic diuretic effect. Strength of Evidence = C  IV administration of diuretics may be necessary. Strength of Evidence = A  Diuretic refractoriness may represent patient nonadherence, a direct effect of diuretic use on the kidney, or progression of underlying dysfunction. Journal of Cardiac Failure Vol. 16 No

55  Prophylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms:  Ischemic etiology Strength of Evidence = A  Non-ischemic etiology Strength of Evidence = B  In patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered. Strength of Evidence = B  Decisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy. Strength of Evidence = C Journal of Cardiac Failure Vol. 16 No

56  Fluid and sodium restriction  Diuretics, especially loop diuretics  Ultrafiltration/renal replacement therapy (in selected patients only)  Parenteral vasodilators * (nitroglycerin, nitroprusside, nesiritide)  Inotropes * (milrinone or dobutamine) Journal of Cardiac Failure Vol. 16 No

57  Recommended prior to discharge for all patients with HF:  Exacerbating factors addressed  Near optimum fluid status and pharmacologic therapy achieved  Transition from IV to oral diuretic completed  Patient education completed with clear discharge instructions  Follow-up clinic visit scheduled, usually 7-10 days  Should be considered prior to discharge for patients with advanced HF or a history of recurrent admissions:  Oral regimen stable for 24 hours  No IV inotrope or vasodilator for 24 hours  Ambulation before discharge to assess functional capacity  Plans for post-discharge management  Referral for disease management, if available Strength of Evidence =C Journal of Cardiac Failure Vol. 16 No

58  Classification and Regression Tree (CART) analysis of ADHERE data shows:  Three variables are the strongest predictors of mortality in hospitalized ADHF patients: BUN > 43 mg/dL Systolic blood pressure < 115 mmHg Serum creatinine > 2.75 mg/dL BUN > 43 mg/dL Systolic blood pressure < 115 mmHg Serum creatinine > 2.75 mg/dL Fonarow GC et al. JAMA 2005;293:572-80

59  It is recommended that patients with HF and their family members or caregivers receive individualized education and counseling that emphasizes self-care.  This education and counseling should be delivered by providers using a team approach.  Teaching should include skill building and target behaviors.  Strength of Evidence = B Journal of Cardiac Failure Vol. 16 No

60 Control Volume Improve Clinical Outcomes Diuretics Renal Replacement Therapy* Digoxin  -Blocker ACEI or ARB Aldosterone Antagonist or ARB Treat Residual Symptoms CRT  an ICD* HDZN/ISDN* *In selected patients

61  For years the discussion has been which antiplatelet regimen is ideal for CHF pts?  ASA  Warfarin  Plavix  WASH Trial  WATCH Trial

62  CHADS 2 C ongestive Heart Failure H ypertension A ge > 75 D iabetes S troke or TIA (2 points)

63  CHA 2 DS 2 -VAS Score Congestive heart failure/LV 1 dysfunction Hypertension1 Age > 75 years2 Diabetes mellitus1 Stroke/TIA2 Vascular disease (prior MI, peripheral 1 vascular disease) Age years1 Female sex1

64 Patient FactorsASAPlavixWarfarin Myocardial Infarction <12months ago XX Stent <12months ago XX Atrial Fibrillation (CHADS2 score 0- 1) X Atrial Fibrillation (CHADS2 score >2) X or Dabigatran DiabetesX BYPASS HxX

65 Patient FactorsASAPlavixWarfarin EF% < 30%X Systolic Failure w/ EF% >30% X Diastolic FailureX Severe CAD (no surgery option) XX LVADXXX

66  New Recommendation VTE prophylaxsis with low dose unfractionated heparin, LMWH, or fondaparinux to prevent proximal deep venous thrombosis and pulmonary embolism is recommended for patients who are admitted to the hospital with ADHF and who are not already anticoagulated & have no contraindication. (Strength of Evidence=B)

67  IMPROVE-HF  Yancy CW, Fonarow GC, Albert NM, et al. Influence of patient age and sex on delivery of guideline-recommended heart failure care in the outpatient cardiology practice setting: Findings from IMPROVE HF. American Heart Journal. 2009;157:  Omega-3 (PUFAs)  Tavazzi L, Maggioni AP, Marchioli R, et al. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomized, double-blind, placebo-controlled trial. Lancet 2008;372:  SELECT Trial  Zebrack J, Munger M, MacGregor J, et al. B-Receptor Selectivity of Carvedilol and Metoprolol Succinate in Patients with Heart Failure (SELECT Trial): A randomized Dose-Ranging Trial. Pharmacotherapy. 2009;29(8):  Irbesartan  Massie b, Carson P, et al. Irbesartan in Patients with Heart Failure & Preserved Ejection Fraction (I-Preserve Trial). NEJM. 2008;359(23):  HFSA “The Heart Failure Clinic A Consensus Statement”  J Card Fail. 2008;14:  Centers for Medicare and Medicaid Services 30 day congestive heart failure readmission rates. 

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69 No significant differences in the patients’ global assessment of symptoms or in changes from baseline renal function with either bolus as compared with continuous infusion of intravenous furosemide or with a low-dose strategy as compared with a highdose strategy.

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72  Teaching tool to utilize with CHF patients  Provides 5yr survival rate for patients based upon clinical history and no intervention as compared to rate after intervention.  User friendly  Internet based 

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75  Based upon the above case what type of interventions would you have expected to have been performed? (during admission or in clinic) A. Continue all medications prior to admission B. Increase Atenolol, start an ace-inhibitor, & start an aldosterone antagonist C. DC atenolol, start metoprolol succinate, & start an ace-inhibitor D. DC atenolol, start carvedilol, & start an ace-inhibitor E. Just give up and discharge patient from clinic!!!

76 Questions???


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